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Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.101 n.9 Cape Town Sep. 2011

Haemorrhage associated with caesarean section in South Africa - be aware

To the Editor: The algorithms in the excellent article in the SAMJ1 for coping with bleeding at caesarean section (CS) cannot be faulted. I add some further comments.

With 2 years of internship, it should be possible to ensure that all trainees are allowed to opt for a 6-month attachment in Obstetrics and Gynaecology if they intend to work in peripheral hospitals, so they are able to do a sufficient number of CSs under supervision before they go to their new posts. My experience over many years with attempting to make interns competent during 4-month rotations was frustrating. They always moved on before I felt they were ready.

The most stable persons in rural obstetric services are usually the Advanced Diploma midwives and theatre-trained nurses. They are often the most competent in labour ward work, too. There may well be virtue in training carefully selected people from among them to do CSs. Our previous attempts to sell that idea to the Health Professions Council were not successful. Perhaps the circumstances have changed sufficiently for them to consider it now?

The practice of closing the uterine wound with a single suture should be abandoned in our teaching hospitals. A double suture technique should be taught. The first suture inserted should include the endometrium, thus ensuring haemostasis in the inside of the uterine wound. The second suture should ensure accurate apposition of the outside of the myometrium, thus ensuring haemostasis just under the peritoneum. It is simply too dangerous to teach staff to trust a single suture that may be poorly applied by inexperienced operators, or which may snap for many reasons, releasing the edges of a highly vascular structure to bleed uncontrollably.

Also, it should be routine to ligate the uterine artery above and below the incision whenever that structure is damaged during a CS. If young surgeons are taught how to do that in well-controlled situations, while protecting the bladder and the ureter from damage, they quickly lose their fear of heavy bleeding from that source, and become very good at securing haemostasis.